Sticks and Stones

On July 14, the Texas Medical Association resigned its membership in the Texas Association of Business & Chambers of Commerce (TABCC), threatening to end a long-standing relationship physicians had enjoyed, for the most part, with one of the state's largest employer and business organizations.

Over the previous 6 years, the relationship among physicians, TABCC, and its predecessor organizations had become rocky. Major disputes among the groups centered around TMA's efforts in major managed care reforms and patients' rights versus employer groups' attempts to hold the line on their members' health care costs.

The two organizations came to blows over a TABCC political fundraising letter this summer that impugned physicians' motives in the managed care fight. The solicitation letter prompted an angry response from TMA and its withdrawal from TABCC.

But what at first appeared to be the final break between two old allies may actually be the beginning of new, improved relationships between the state's leading physician and employer groups, thanks to a quick apology from TABCC President Bill Hammond. While that improved relationship may be a long way from fruition, leaders of both organizations have expressed a renewed interest in trying to resolve their differences.

Falling out between friends

How two old friends ended up at odds is a long story. Physicians and business have been traditional allies on a number of issues, most notably tort reform. Throughout the late 1980s and early 1990s, physicians and employers worked closely on tort issues, culminating in passage of a major tort reform package in 1995.

They also cooperated extensively in efforts to oust pro-trial lawyer judges from the Texas Supreme Court and replace them with conservative justices who would uphold the laws on the books, not legislate from the bench.

Even as late as 1994, physicians and employers cooperated on the national level to defeat First Lady Hillary Rodham Clinton's proposal to overhaul the US health care system.

But relations started to change in 1995 when TMA backed the first Patient Protection Act in the Texas Legislature. Business and employer groups sided with the health maintenance organizations (HMOs) against that bill and convinced Gov George W. Bush to veto it.

Physicians again passed major managed care and patients' rights reforms in 1997 and 1999. During those sessions, rhetoric between physicians and some employer groups, most notably TABCC, became increasingly caustic.

Seeking new allies

With the statewide chamber drawing a line in the sand on managed care issues, TMA turned to other employer groups for input on its attempts to reform managed care. In 1997, TMA and the Texas Business Group on Health (TBGH), an association of benefits managers for large employers, opened a dialogue on managed care issues that helped craft the HMO liability law enacted by the legislature that year.

"As the relationship with the chamber deteriorated and the rhetoric accelerated, we decided that we were going to have to find a more reliable source of information and policy expertise in the employer community," said Kim Ross, TMA vice president for public policy. "So we reached out to the Texas Business Group on Health with extraordinary success."

Mr Kimmich, through his participation in the Dallas-Fort Worth Business Group on Health, already had a relationship with Dallas-area physicians. Michael Darrouzet, executive officer of the Dallas County Medical Society, says physicians and the local business group were able to identify potential solutions to health care issues of mutual concern.

Mr Samuels also was willing to help facilitate that dialogue. "I guess I had a different political calculation than the other business and insurance lobbyists at the time," he said. He believed the political climate had changed since 1995 and that TMA's managed care reforms likely would become law despite employers' opposition and Governor Bush's previous veto.

Houston oncologist Joseph S. Bailes, MD, chair of TMA's Council on Legislation at the time, says two key elements made the discussions with TBGH successful. The first was personalities. "Ralph Kimmich and I hit it off very well," he said. The second was getting the lobbyists out of the room and letting physicians and employers hash out the issues themselves.

In work sessions in which the lobbyists voluntarily excluded themselves, progress was made on two aspects of the HMO liability bill that benefited physicians and patients, as well as employers. The first was language that exempted employers from liability. The second was creation of an independent review process that would slow down potential lawsuits but, at the same time, offer patients the opportunity to get the care they needed in a timely manner.

No good deed …

While physicians were pleased with the cooperation between TMA and TBGH in the 1997 legislative session, other employer groups were not.

"It would be fair to say that Ralph Kimmich took a lot of heat for his position within the Business Group on Health as being too moderate, too willing to work with physicians," Mr Darrouzet said. "Subsequent presidents have taken a little harder line."

Meanwhile, relationships continued to deteriorate. TABCC again sided with the for-profit HMOs in 1999 when TMA pushed through the physician negotiation bill. That led directly to the solicitation letter that proved to be the final straw.

In June, TABCC sent the letter to members of its Health Partners Task Force, seeking contributions to fund its legislative lobbying activities in 2001. Health Partners is a group dominated by for-profit managed care organizations.

The letter accused physicians of attempting to create "doc cartels" through the physician negotiation legislation.

"You can rest assured the docs will be back next session in an effort to make the law more amenable to their pocketbooks," Mr Hammond wrote in the solicitation letter.

That letter prompted TMA's immediate withdrawal from TABCC. In a July 14 letter signed by TMA President Jim Rohack, MD, of Temple, and TMA Executive Vice President Louis J. Goodman, PhD, TMA accused the employer group of "antagonistic and pejorative" rhetoric against physicians.

"While we respect the right of your organization to advocate on behalf of your members, it makes no sense for TMA to contribute to an effort that continues to impugn the motives of the medical profession and assert adversarial positions without the advice or opinions of its physicians members," the letter stated.

Dr Rohack and Dr Goodman concluded, "It is an unfortunate, missed opportunity that one of the forums for employer health care concerns is conducted in such a malevolent and parochial manner."

Not only did TMA react, but also did a number of local chambers of commerce, which typically enjoy a much friendlier relationship with their local physicians than has the statewide organization.

In an August 16 letter to Mr Hammond, the Abilene Chamber of Commerce demanded that none of its membership funds be used to support the Health Partners Task Force.

"The membership of the Abilene Chamber of Commerce includes numerous physicians and health care professionals, who are valuable members of our community and contributors to our local economy and civic improvements," wrote Royce Money, PhD, board chair for the Abilene chamber and president of Abilene Christian University. "They work in a highly regulated and stressful profession within an increasingly complex health care delivery system. We cannot condone the rhetoric that the Health Partners Task Force uses with regard to these individuals."

Mending the fence

Under pressure from local chambers, Mr Hammond issued an apology to TMA, took full responsibility for what he called an "inappropriate" characterization of physicians, and thanked Drs Rohack and Goodman "for bringing my error to light."

"Stating that doctors 'will be back next session to make the law more amenable to their pocketbooks' is an inflammatory statement to all physicians of this state who have dedicated their lives to improving the quality of our lives," he wrote.

"The affiliation between TABCC and TMA goes back more than a decade, and together we have worked to successfully shepherd through the legislative process issues of vital importance to business, physicians, and all Texans," Mr Hammond wrote in an August 30 letter to Dr Rohack. "It has long been our hope that we can enter into an open dialogue on our goals of affordable, accessible, and quality health care for all Texans."

Mr Hammond also offered TMA free membership in TABCC for 2001 and asked to meet with key TMA staff and physician leaders. There has been one meeting at the staff level.

TMA's Board of Trustees is mulling TABCC's membership offer, but Dr Rohack says a new dialogue with TABCC will go forward. "It isn't the money of the membership that's the issue," he said. "Accepting a free membership without discussing what created the problem and making sure we have resolution doesn't make sense. Within the next few weeks there will be an attempt to sit down with their leadership to talk about our differences and how we can work together."

Mr Hammond also sees a new opportunity for discussion. "I think this gives us the opportunity to explore much more carefully and in a much more disciplined manner opportunities for agreement on managed care issues," he said. "This wasn't pleasant, but the fact of the matter is I think our relationship is enhanced and now we have a clean slate and an opportunity to move ahead."

Where to now?

The 77th Texas Legislature, which convenes in January 2001, will present a number of issues that likely will challenge the physician-employer relationship and provide opportunities for cooperation. Among high-profile issues confronting the next legislature will be patient safety, physician profiling, workers' compensation, prescription drug coverage, health care fraud, medical privacy, mandated benefits, and coverage for the uninsured.

Dr Rohack says that opportunities should arise for physicians and employers to work together on the uninsured and mandates. Both impact the cost of care and should be of mutual concern.

Mr Hammond also points to workers' compensation as an issue for which cooperation may be possible. TABCC plans to focus on removing health care professionals, particularly chiropractors, that the group feels are abusing the system and driving up costs.

"There's something called the preferred doctor list for workers' compensation, and we'd like to see those who are abusing the system removed from it," he said. "That would benefit all providers whether they are chiropractors or physicians."

TMA also is examining that issue. During its meeting in September, the TMA House of Delegates considered a resolution directing TMA to support amending the Texas Workers' Compensation Act to mandate that all treating doctors be licensed doctors of medicine or osteopathy. It was referred to the Council on Legislation. The resolution stemmed from a growing concern among physicians about the quality of care provided under workers' compensation.

Controlling health care costs, however, may present a challenge. "Our so-called health care system is rapidly deteriorating," Mr Ross said. "It is fragmented, inefficient, and probably under-financed given the rising demand for health care services from an aging population. The legislature and eventually the US Congress will have some very tough choices ahead of them. It only makes sense that those who pay for and those who provide health care services collaborate on both short- and long-term solutions. We need each other if we are to find an equitable path through these dangerous times."

Meanwhile, there may be additional opportunities to work together on nonhealth issues. "Doctors are employers, and if you look at the entire range of issues that we work on, outside of health insurance, I think there would be an enormous amount of agreement among your members with our agenda," Mr Hammond said. "We need to finish the job on tort reform. We would like to see meaningful class action reform. We want third-party and premises liability cleaned up. Those are several specific issues that TMA has worked on in the past and I think we could work together on in the future."

Dr Rohack says TMA is ready to focus on common goals rather than differences. "We're committed to the citizens of Texas because they are our patients," he said. "Employers need to have healthy citizens, not only to be employees but also to be consumers of their products. We look forward to working with their leadership on this common goal so they as employers can have a healthy workforce and we as physicians can provide the best care possible."

Ken Ortolon can be reached at (800) 880-1300, ext 1392, or (512) 370-1392; or by email at Ken Ortolon.